The form for the certificate of land use restriction required by KRS 100.3681 shall be as follows: CERTIFICATE OF LAND USE RESTRICTION 1. NAME AND ADDRESS OF PROPERTY OWNER(s) ................................................. ............................................................................. ................................................. ............................................................................. ................................................. ............................................................................. 2. ADDRESS OF PROPERTY 3. NAME OF SUBDIVISION OR DEVELOPMENT (if applicable) ................................................. ............................................................................. ................................................. ............................................................................. ................................................. ............................................................................. 4. TYPE OF RESTRICTION(s) (Check all that apply): .......Zoning Map Amendment to Zone .....Conditional Zoning Condition .......Development Plan .....Other ..................................................... specify .......Unrecorded Subdivision Plat .......Variance .......Conditional Use Permit 5. NAME AND ADDRESS OF PLANNING COMMISSION, BOARD OF ADJUSTMENT, LEGISLATIVE BODY OR FISCAL COURT WHICH MAINTAINS THE ORIGINAL RECORDS CONTAINING THE RESTRICTION .................................................. .................................................. .................................................. .................................................. .................................................. .............................................................. Signature of Completing Official .............................................................. Name and Title of Completing Official (Type or print)
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